PCR BH Provider Resource Guide

The Peninsula Coastal Region Behavioral Health (PCR BH) panel serves approximately 12,000 employees and their dependents who are members of the SutterSelect PCR health plan. The following information serves as a resource guide for providers on the PCR BH panel.

Member Benefits

The SutterSelect PCR health plan’s mental health and substance disorder benefit encompasses all levels of care (facility-based inpatient, partial hospitalization, intensive outpatient, residential levels, and provider-based outpatient treatment) for medically necessary treatment. For a full list of coverage and exclusions refer to the SutterSelect Peninsula Coastal Region Self-Funded Health Plan Summary Plan Description (SPD). If providers or members have concerns regarding whether a diagnosis or treatment procedure is a covered benefit, they can also contact PCR BH by calling (855) 729-4390 or complete a Prior Certification Request.
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Member ID Cards

Members will receive a member ID card that contains the following information:

Member Access to Care

Members Seeking ServiceIf a member contacts PCR BH for assistance in locating a provider, appropriate providers will be identified and contacted. Providers are expected to respond promptly to calls from PCR BH. If the provider accepts the case, the member will be notified to call the provider for an appointment.

Facility Treatment ReferralsIf a provider determines that the member needs and would benefit from facility-based treatment, the provider should contact PCR BH (24/7) to obtain Prior Certification. If urgent or emergent, the member should be directed to the nearest behavioral health facility or emergency room.

Informed Consent

At the first outpatient session, members must be asked to read and sign the provider’s informed treatment consent statement and related HIPAA consents. The informed treatment consent should include notification regarding confidentiality (Tarasoff, duty to report child and elder abuse, threat to self), responsibility for copays and medical necessity. This form must be maintained in the member’s patient record.
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Member Copays

Worker's Compensation

If the provider determines that the member’s condition is a function of a workplace injury or workplace emotional/psychological abuse or stress, the provider or member should contact PCR BH for direction. Further treatment should not be provided without first notifying PCR BH.
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Treatment for Non-covered Services or Lack of Medical Necessity

If a member receives a denial of a prior certification request due to the condition being excluded from the plan or due to lack of medical necessity, the provider may provide treatment to the member on a self-pay basis. However, the provider is expected to have the member sign a statement that explains all payment for the treatment is the responsibility of the member.
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Expectations of Providers

Providers are expected to maintain the following standards of care and conduct:

Notify PCR BH of changes to their availability and to obtain coverage by another PCR BH provider during any absences.

Have a greeting on their telephone answering message which informs members how to reach them in urgent situations and to go to an emergency room or to call "911" in an emergent situation.

Maintain ethical and legally mandated professional conduct at all times in treating and responding to members and former members.

Provide for the orderly transition of care throughout treatment levels in such a manner that the member receives continued clinical support with clinical information, whenever possible, preceding the transition through levels of care and providers.

Seek consultation when appropriate.

Maintain federal and state confidentiality laws and regulations, including HIPAA requirements for the protection of personal health information.

Maintain separate clinical records for each member, containing assessments, progress notes, releases and consents. Each member is expected to have a written clinical assessment and treatment plan no later than by the end of the third session.

Communicate with the member’s physician and/or other mental health/substance disorder providers to provide for coordination of care.

Provider Website

The SutterSelect Provider website sutterselect.tpa.com provides access to information and tools for managing your patients covered by SutterSelect 24 hours a day, seven days a week. Logging on to this website provides you and your office the following:

Claim inquiry information such as payment status, amounts billed and paid, deductibles, discounts and to whom payment was made.

Access to the SutterSelect Peninsula Coastal Region Self-Funded Health Plan Summary Plan Description (SPD). The SPD is the official legal document for the medical plan. The SPD describes what benefits are available under the plan, the rights of members under the plan and how the plan works.

A guide to navigating the provider website is available in the SutterSelect Administrative Manual. This Manual is also located online at sutterselect.tpa.com. If you do not already have a username and logon, click "Need a Username? Register here." to complete the registration process using your name and password.